CITY_OF_EDINBURG_000243483_AL_-_City_of_Edinburg_Utilization_Analysis_(Oct_'24_to_Sept_'25).pdf

Blue Insight℠ Utilization Analysis Report

Incurred_10/01/2024 to 09/30/2025 Paid 10/01/2024 to 11/30/2025

CITY OF EDINBURG 000243483: ALL

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association © Copyright 2026 Health Care Service Corporation. All rights reserved.

Data Parameters 3

Executive Summary 4

Executive Summary Dashboard 5

Enrollment Overview 6

Key Indicators 7-8

Top Diagnostic Categories 9

Musculoskeletal and Connective Tissue 10

Neoplasms 11

Circulatory 12

Adult Chronic Conditions Analysis 13

High Cost Claimants Overview 14

High Cost Claimants Trend 15

High Cost Claimants Additional Details 16

High Cost Claimants Diagnostic Categories 17

High Cost Claimants Listing 18

Inpatient Facility Overview 19

Inpatient Facility – Details by Service Type 20

PLAN PERFORMANCE

Inpatient Deliveries 21

Inpatient Provider Summary 22

Outpatient Facility Overview 23

Outpatient Facility – Details by Service Type 24

Emergency Room Overview 25

Emergency Room – Leading Diagnoses 26

Frequent Users of the Emergency Room 27

Outpatient Provider Summary 28

Professional Services Overview 29

Professional Services – Details by Service Type 30

Preventive Care 31

Pharmacy Overview 32

Pharmacy: Top Non-Specialty Therapeutic Drug Classes 33

Pharmacy: Specialty Drug Analysis 34

Appendix: Financial Summary 35

Appendix: Glossary 36

CITY OF EDINBURG 000243483: ALL

Table of Contents

Data Parameters 3

Executive Summary 4

Executive Summary Dashboard 5

Enrollment Overview 6

Key Indicators 2 7

Top Diagnostic Categories 8

Adult Chronic Conditions Analysis 9

High Cost Claimants Trend 10

High Cost Claimants Additional Details 11

Inpatient Facility Overview 12

PLAN PERFORMANCE

Outpatient Facility Overview 13

Emergency Room Overview 14

Emergency Room – Leading Diagnoses 15

Frequent Users of the Emergency Room 16

Professional Services Overview 17

Preventive Care 18

Appendix: Glossary 19

CITY OF EDINBURG 000243483: ALL

Table of Contents

Benchmark data is based on Texas group population. Select benchmark utilization and expense measures, such as PMPMs and rates per 1,000, have been adjusted to reflect the group's age and gender distribution.

High Cost Claimants are defined as members with paid expenses greater than $50,000_within the reporting period.

The report includes medical and pharmacy claims.

Reporting Segments: ALL Characteristics: ALL Group/Sections: ALL Member MSA: ALL Group: ALL Medicare Primary Indicator: ALL Funding Type: ALL Product Type: ALL Employee Status: ALL Database(s): CITY OF EDINBURG 000243483: ALL

Reporting Support Contact Information

For reporting support, please contact Client Reporting Service Center Email: client_reporting@bcbsil.com Hours of Operation: Monday - Friday: 8:00am - 5:00pm CT

Report prepared on 07/02/2026

Current Reporting Period: The current reporting period represents claims incurred from October 1, 2024 through September 30, 2025 and paid October 1, 2024 through November 30, 2025.

Prior Reporting Period: The prior reporting period represents claims incurred from October 1, 2023 through September 30, 2024 and paid October 1, 2023 through November 30, 2024.

CITY OF EDINBURG 000243483: ALL

Data Parameters

CITY OF EDINBURG 000243483: ALL’s overall enrollment decreased by_2.0%_between the two reporting periods. The average age among CITY OF EDINBURG 000243483: ALL’s members increased from 33.2 to 33.3_years of age. The gender mix of the population was 37.9%_female and 62.1%_male.

The overall paid expense per member per month (PMPM) increased by_39.1%_between the two reporting periods. The service category that impacted the paid PMPM trend the most was_inpatient facility, which increased by_>100%. Additionally, paid PMPM for CITY OF EDINBURG 000243483: ALL_was_7.2%_lower than_the benchmark.

Inpatient paid PMPM increased by_>100%_between reporting periods. The top two admission types by paid PMPM were Complex Newborns_and_Surgical. Complex Newborns_increased by_>100%. Surgical_increased by_16.9%.

Outpatient paid PMPM increased by_12.7%_between reporting periods. The top two outpatient facility visit types by paid PMPM were Surgical_and Emergency Room. Surgical_increased by_18.6%._Emergency Room_increased by_18.4%.

Professional paid PMPM increased by_27.1%_between reporting periods. The top two professional service types by paid PMPM were Evaluation & Management_and Pathology & Laboratory. Evaluation & Management_increased by_21.5%. Pathology & Laboratory_increased by_12.2%.

CITY OF EDINBURG 000243483: ALL’s overall top four diagnostic categories by paid expense PMPM were_Neoplasms, Perinatal, Circulatory, and Health Status.These four diagnostic categories accounted for 52.4% of the overall paid expenses in the current reporting period.

For high cost claimants the total paid expenses increased by_89.8%_between the two reporting periods. HCCs are defined as claimants whose total expense equaled or exceeded $50,000. The number of HCCs also increased by_20.8%_from 24_to_29_during the same time frame. The proportion of paid expenses due to high cost claimants increased from 35.7% to 49.7% between reporting periods.

Paid PMPM for Emergency Room (ER) visits increased by_18.4%_between reporting periods.Total ER visits/1,000 increased by_12.5%_in the current reporting period and was 7.3%_lower than_the benchmark.

In the current reporting period, primary care physicians (PCP) accounted for 38.6%_of professional office visits compared to 29.5%_for the benchmark. PCPs accounted for 29.6%_of professional office expenses.

Medical paid PMPM increased by_48.0%_between reporting periods and was_4.0%_lower than_the benchmark.

Pharmacy paid PMPM_increased by_17.4%_between reporting periods.

CITY OF EDINBURG 000243483: ALL

Executive Summary

Oct 2023 - Sep

Oct 2024 - Sep 2025 % Change Benchmark

Allowed $9,748,746 $12,479,755 28.0%

Paid $7,775,466 $10,597,951 36.3%

Paid PMPM $371.45 $516.67 39.1% $556.70

Medical Plan Performance

Plan Share 79.9% 84.2% 84.2%

In-Network Paid % 99.9% 99.9% 99.1%

Discount % 75.5% 71.8% 63.6%

Members 1,744 1,709 -2.0%

Subscribers 1,099 1,099 0.0%

Dependents 645 610 -5.4%

Key Metrics

Paid

PMPM

39.1%

Claimant Distribution % of Total Paid % of Total Unique Members

Dollar Range Prior Current Benchmark Prior Current Benchmark Non-Utilizers 0.0% 0.0% 0.0% 19.8% 19.9% 19.0%

$0-$50K 64.3% 50.3% 50.6% 79.0% 78.7% 79.2%

$50K-$100K 11.5% 7.7% 14.7% 0.7% 0.6% 1.1%

$100K-$300K 19.4% 17.8% 20.2% 0.4% 0.7% 0.6%

$300K and + 4.9% 24.3% 14.4% 0.0% 0.3% 0.1%

HCC Subtotal 35.7% 49.7% 49.4% 1.2% 1.5% 1.8%

Utilization

Cost and Case Mix

High Cost Claimants

Benchmark

2.5%

1.4%

7.1%

CITY OF EDINBURG 000243483: ALL

Executive Summary Dashboard

Reporting Period Oct 2023 - Sep 2024

Oct 2024 - Sep 2025 % Change Benchmark

Benchmark Variance

Average Membership 1,744 1,709 -2.0% Employee 1,099 1,099 0.0% Spouse 116 109 -6.2% Dependent 529 502 -5.2% Average Contract Size 1.6 1.6 -2.0% 1.8 -15.8% Average Age 33.2 33.3 0.3% 34.9 -4.7% Employee 41.4 41.4 -0.1% 44.4 -6.9% Spouse 44.0 43.1 -2.0% 47.2 -8.6% Dependent 13.6 13.3 -2.2% 13.0 2.5%

% Under 30 45.2% 44.6% 41.0% % 30 to 49 33.9% 34.4% 32.7% % 50 to 64 19.7% 19.7% 22.5% % 65+ 1.3% 1.3% 3.8% Gender % of Males 62.6% 62.1% 49.9% % of Females 37.4% 37.9% 50.1% % of Females Ages 20-44 17.0% 16.9% 20.6%

• Overall, membership decreased by_2.0%_between reporting periods.

• The average age was 33.3and increased by_0.3%_between reporting periods.

• Contract size decreased by_2.0%_between reporting periods.

• The percentage of females between ages 20 and 44 decreased from_17.0% to 16.9%_between reporting periods.

CITY OF EDINBURG 000243483: ALL

Enrollment Overview

The above chart shows the % change from prior period to current period in paid PMPM, the % change in the amount paid per service (cost), and the % change in the number of services per 1,000 (utilization) by service category.

$516.67 Current Paid

PMPM

39.1% Change Year

Over Year

7.2% Lower than Benchmark

Cost Utilization Cost Utilization Cost Utilization

>100% 11.3% 7.0% 5.3% 6.9%18.9%

Cost Utilization

17.8% -0.4%

Inpatient Facility

Outpatient Facility

Professional

39.1%

PMPM

>100%

IP PMPM

12.7%

OP PMPM

27.1%

PS PMPM

Pharmacy

17.4%

RX PMPM

CITY OF EDINBURG 000243483: ALL

Key Indicators

• Total medical paid PMPM increased_48.0%_in the current reporting period and was4.0%_below_the benchmark.

• Excluding high cost claimants, the total paid PMPM trend was 8.8%.

Service Category Reporting Period

Oct 2023 - Sep 2024

Oct 2024 - Sep 2025 % Change Benchmark

Benchmark Variance

Inpatient Facility

Paid PMPM $66.78 $156.31 >100% $106.27 47.1% Paid PEPM $105.98 $243.14 >100% $201.73 20.5% Allowed PMPM $94.77 $171.73 81.2% $120.73 42.2% Admissions/1,000 44.1 49.1 11.3% 44.5 10.5% Days/1,000 206.9 273.8 32.3% 238.5 14.8% Average Length of Stay 4.7 5.6 18.8% 5.4 3.9% Paid/Admission $18,154 $38,170 >100% $28,677 33.1% Paid/Day $3,872 $6,851 76.9% $5,347 28.1%

Outpatient Facility

Paid PMPM $114.03 $128.52 12.7% $153.83 -16.4% Paid PEPM $180.98 $199.92 10.5% $297.63 -32.8% Allowed PMPM $144.04 $165.63 15.0% $201.41 -17.8% Visits/1,000 1,222.8 1,287.6 5.3% 1,266.7 1.7% Paid/Visit $1,119 $1,198 7.0% $1,457 -17.8%

Professional

Paid PMPM $82.85 $105.33 27.1% $146.42 -28.1% Paid PEPM $131.49 $163.84 24.6% $288.18 -43.1% Allowed PMPM $111.41 $136.32 22.4% $187.73 -27.4% Services/1,000 20,526.1 21,940.1 6.9% 21,014.1 4.4% Paid/Service $48 $58 18.9% $84 -31.1%

Medical Summary

Paid PMPM $263.65 $390.17 48.0% $406.51 -4.0% Paid PEPM $418.46 $606.90 45.0% $787.53 -22.9% Allowed PMPM $350.22 $473.68 35.3% $509.87 -7.1% In-Network Paid % 99.9% 99.9% 99.1% In-Network Services % 98.7% 99.3% 98.3% Plan Share % 79.9% 84.2% 84.2%

Pharmacy

Rx Paid PMPM $107.79 $126.50 17.4% $150.19 -15.8% Rx Paid PEPM $171.09 $196.77 15.0% $282.68 -30.4% Rx Allowed PMPM $115.49 $134.73 16.7% $165.17 -18.4% Prescriptions/Member 11.4 11.4 -0.4% 12.9 -11.6% Paid/Prescription $113 $134 17.8% $140 -4.7%

Overall Summary

Paid PMPM $371.45 $516.67 39.1% $556.70 -7.2% Paid PEPM $589.54 $803.67 36.3% $1,070.21 -24.9% Allowed PMPM $465.71 $608.41 30.6% $675.04 -9.9%

CITY OF EDINBURG 000243483: ALL

Key Indicators

Diagnostic Categories with Paid PMPM Oct 2023 - Sep 2024

Oct 2024 - Sep 2025

% Change Benchmark Benchmark Variance

Neoplasms $39.63 $73.96 86.6% $49.06 50.8%

Perinatal $2.09 $53.70 >100% $10.96 >100%

Circulatory $36.22 $43.50 20.1% $42.94 1.3%

Health Status $30.46 $33.35 9.5% $35.28 -5.5%

Injury/Poisoning $9.96 $19.13 92.1% $30.96 -38.2%

Genitourinary $12.92 $18.82 45.6% $19.54 -3.7%

Endocrine $11.64 $16.85 44.8% $13.78 22.3%

Musculoskeletal $7.36 $16.60 >100% $40.67 -59.2%

Symptoms/Ill-Defined $17.32 $15.54 -10.3% $22.64 -31.4%

Digestive $21.75 $15.08 -30.6% $29.59 -49.0%

All Others $74.32 $83.62 12.5% $111.09 -24.7%

Total $263.65 $390.17 48.0% $406.51 -4.0%

• Neoplasms_was the most costly diagnostic category and paid_PMPM _increased_86.6%_ between reporting periods.

• The top 4 diagnostic categories accounted for _52.4%_ of total medical costs in the current period.

• The_Perinatal_category experienced the largest percentage increase in the current period.

CITY OF EDINBURG 000243483: ALL

Top Diagnostic Categories

Reporting Period Oct 2023 - Sep 2024 Oct 2024 - Sep 2025 % Change Benchmark Benchmark

Variance

Inpatient

Paid PMPM $0.70 $3.22 >100% $6.33 -49.1%

Admissions/1,000 0.6 1.2 >100% 1.3 -9.5%

Paid/Day $244 $7,341 >100% $13,449 -45.4%

Paid/Admission $14,631 $33,036 >100% $58,683 -43.7%

Outpatient

Paid PMPM $3.78 $8.92 >100% $18.17 -50.9%

Visits/1,000 75.7 127.5 68.5% 154.9 -17.7%

Paid/Visit $600 $839 39.9% $1,408 -40.4%

Professional

Paid PMPM $2.88 $4.46 55.1% $16.18 -72.4%

Services/1,000 1,099.5 1,307.5 18.9% 2,653.1 -50.7%

Paid/Service $31 $41 30.4% $73 -44.0%

Total Medical

Paid PMPM $7.36 $16.60 >100% $40.67 -59.2%

Non High Cost $6.91 $9.78 41.6% $21.40 -54.3%

High Cost $0.45 $6.83 >100% $19.28 -64.6%

Paid/Claimant $435 $984 >100% $1,588 -38.0%

Claimants/1,000 202.9 202.4 -0.3% 254.3 -20.4%

% of Total Medical Paid 2.8% 4.3% 10.6%

Musculoskeletal paid PMPM accounted for 4.3%_of the total medical paid PMPM

Pa id

P M

PM

$0 Spinal Surgery Knee Replacement

Hip Replacement

Prior $0.07 $0.00 $0.00

Current $2.80 $0.47 $0.36

Benchmark $5.61 $1.35 $0.94

M ed ic al

C la im an ts /1

,0

0 Spinal Surgery Knee Replacement

Hip Replacement

Prior 0.6 0.0 0.0

Current 0.6 1.2 0.6

Benchmark 1.8 1.3 0.8

Common Musculoskeletal Surgical Procedures Paid PMPM

Common Musculoskeletal Surgical Procedures Claimants/1,000

CITY OF EDINBURG 000243483: ALL.

Musculoskeletal and Connective Tissue

Variance Inpatient

Paid PMPM $1.92 $32.81 >100% $9.19 >100%

Admissions/1,000 1.7 6.4 >100% 2.0 >100%

Paid/Day $8,041 $8,628 7.3% $9,221 -6.4%

Paid/Admission $13,401 $61,182 >100% $54,463 12.3%

Outpatient

Paid PMPM $29.94 $30.49 1.8% $26.90 13.3%

Visits/1,000 106.6 69.6 -34.7% 72.8 -4.4%

Paid/Visit $3,369 $5,255 56.0% $4,433 18.5%

Professional

Paid PMPM $7.77 $10.67 37.3% $12.97 -17.7%

Services/1,000 499.9 563.4 12.7% 607.2 -7.2%

Paid/Service $187 $227 21.8% $256 -11.3%

Total Medical

Paid PMPM $39.63 $73.96 86.6% $49.06 50.8%

Non High Cost $4.67 $5.45 16.7% $7.85 -30.6%

High Cost $34.96 $68.51 96.0% $41.20 66.3%

Paid/Claimant $10,369 $17,240 66.3% $6,329 >100%

Claimants/1,000 45.9 51.5 12.3% 84.7 -39.2%

% of Total Medical Paid 15.0% 19.0% 13.2%

5.2%_of members had a Neoplasms diagnosis compared to 10.1%_of the book of business members

Breast Cervical Colorectal Endocrine Leukemia Lymphoma Melanoma Non-

Melanoma Prostate Respiratory Claimants 4.6% 1.1% 5.7% 2.3% 0.0% 5.7% 0.0% 2.3% 3.4% 1.1%

Paid 4.0% 0.0% 11.1% 0.8% 0.0% 54.0% 0.0% 0.3% 0.0% 0.1%

CITY OF EDINBURG 000243483: ALL

Neoplasms

Variance

Inpatient

Paid PMPM $14.33 $30.31 >100% $19.93 52.1%

Admissions/1,000 10.3 5.9 -43.3% 5.6 4.2%

Paid/Day $5,358 $10,029 87.2% $8,211 22.1%

Paid/Admission $16,669 $62,182 >100% $42,595 46.0%

Outpatient

Paid PMPM $16.74 $6.45 -61.5% $14.87 -56.6%

Visits/1,000 79.1 90.7 14.6% 80.3 12.9%

Paid/Visit $2,539 $854 -66.4% $2,222 -61.6%

Professional

Paid PMPM $5.14 $6.73 31.0% $8.14 -17.2%

Services/1,000 1,651.0 1,633.4 -1.1% 1,136.3 43.7%

Paid/Service $37 $49 32.4% $86 -42.4%

Total Medical

Paid PMPM $36.22 $43.50 20.1% $42.94 1.3%

Non High Cost $13.70 $11.35 -17.1% $13.48 -15.8%

High Cost $22.52 $32.15 42.8% $29.46 9.1%

Paid/Claimant $1,919 $2,330 21.4% $2,437 -4.4%

Claimants/1,000 226.4 224.1 -1.0% 193.8 15.6%

% of Total Medical Paid 13.7% 11.1% 10.2%

Circulatory paid PMPM accounted for 11.1%_of the total medical paid PMPM

Pa id

P M

PM

$0 Gangrene Stroke Coronary Heart Disease

Heart Attack Heart Valve Disease

Prior $0.00 $1.85 $4.62 $2.99 $0.00

Current $8.34 $7.36 $5.35 $4.66 $3.34

Benchmark $0.30 $3.15 $2.36 $3.21 $1.23

Inpatient Circulatory Top Five Diagnoses by Paid PMPM

CAD Diabetes CHF Hyperlipidemia Hypertension Current 21.1 86.0 4.1 146.3 170.2

Benchmark 19.9 40.6 6.9 87.1 126.1

Common Circulatory Comorbidity: Claimants/1,000

Claimants can be counted in more than one chronic condition category.

CITY OF EDINBURG 000243483: ALL

Circulatory

Oct 2024 - Sep 2025 Benchmark

Benchmark Variance

CHF 5.8 9.6 -39.4%

CAD 31.3 30.0 4.5%

Claimants/1,000 Diabetes 175.6 104.9 67.5%

Hyperlipidemia 372.4 231.2 61.1%

Hypertension 274.7 225.7 21.7%

No Chronic Conditions 459.1 645.4 -28.9%

CHF $37,302 $46,621 -20.0%

CAD $31,418 $22,345 40.6%

Paid/Claimant Diabetes $19,116 $11,203 70.6%

Hyperlipidemia $11,015 $7,195 53.1%

Hypertension $14,858 $9,849 50.9%

No Chronic Conditions $1,645 $2,422 -32.1%

CHF $18.12 $37.17 -51.2%

CAD $82.04 $66.37 23.6%

Paid PMPM Diabetes $279.77 $147.66 89.5%

Hyperlipidemia $341.82 $220.07 55.3%

Hypertension $340.16 $252.19 34.9%

No Chronic Conditions $62.94 $148.63 -57.7%

• Hyperlipidemia_was the most prevalent chronic condition and was above the benchmark.

• CHF_was the most costly chronic condition on a Paid/Claimant basis and was below the benchmark.

* For a member to be included in one of these chronic condition categories, they must be 18 years or older and have had at least two claims for one of the chronic condition categories that were incurred within 180 days of each other and paid within the last 39 months. Paid per claimant and Paid PMPM rates are for those members in each chronic condition category for the most current reporting period. Costs include the total claimant cost and are not limited to the cost of the chronic condition. This report includes medical and pharmacy claims where applicable. Claimants and their claim spend can be counted in more than one chronic condition category in this report. CAD: Coronary Artery Disease; CHF: Chronic Heart Failure.

Per the American Heart Association, three of the seven key health factors that increase the risks for heart disease and stroke include: High Blood Pressure (Hypertension), High Cholesterol (Hyperlipidemia) and High Blood Glucose (Diabetes). The below chart and bar graphs show key metrics for CITY OF EDINBURG 000243483: ALL for five types of chronic conditions* along with comparative data for members who did not have any known type of chronic condition. All data reflects members aged 18 and above.

CITY OF EDINBURG 000243483: ALL

Adult Chronic Conditions Analysis

1.70% Of Membership

2.34%_Benchmark

49.7% of Total Paid

49.4%_Benchmark Accounted for

High Cost Claimants

24_prior

24.1% Repeat HCCs 28.8%_Benchmark

$5.3M Total Paid

$2.8_M_in prior period

62.1% Employees

60.6%_Benchmark

Average Age

46_Benchmark

41.4% Female

52.5%_Benchmark

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Overview

Oct 2023 - Sep 2024 Oct 2024 - Sep 2025 % Change Benchmark Benchmark Variance High Cost Claimants 24 29 20.8%

% of Total Members 1.38% 1.70% 2.34%

HCC Paid $2,775,634 $5,266,786 89.8%

% of Total Paid 35.7% 49.7% 49.4%

Total Paid PMPM $371.45 $516.67 39.1% $556.70 -7.2%

Non-High cost $238.85 $259.90 8.8% $285.89 -9.1%

High Cost $132.60 $256.77 93.6% $270.81 -5.2%

HCC Paid/Claimant $115,651 $181,613 57.0% $135,850 33.7%

• 1.70%_of members were high cost claimants in the current period compared to 1.38%_in the prior period and 2.34%_for the benchmark.

• High cost claimants accounted for_49.7%_of total costs in the current period compared to 35.7%_in the prior period and 49.4%_for the benchmark.

• Paid PMPM for high cost claimants _increased by_93.6%_between the two reporting periods and was_5.2%_lower than_the benchmark.

• Paid PMPM excluding high cost claimants increased by_8.8%_between the two reporting periods and was 9.1%_lower than_the benchmark.

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Trend

• The_$300,000+_paid band experienced the largest percent increase_in paid dollars in the current reporting period.

• 29_claimants accounted for 49.7%_of the total paid amount in the current reporting period.

• By service category, Inpatient Facility_accounted for the largest percent of high cost claimant paid dollars in the current reporting period.

• Employee_accounted for the largest percent of high cost claimant paid dollars in the current reporting period.

Claimant Distribution by Paid Band

Oct 2023 - Sep 2024 Oct 2024 - Sep 2025 % Change Dollar Range Claimants Paid Paid % Claimants Paid Paid % Claimants Paid No Claims 400 $0 0.0% 396 $0 0.0% -1.0% 0.0%

$0-$49,999 1,599 $4,999,832 64.3% 1,569 $5,331,165 50.3% -1.9% 6.6%

$50,000-$99,999 14 $892,574 11.5% 11 $811,193 7.7% -21.4% -9.1%

$100,000-$299,999 9 $1,504,784 19.4% 13 $1,884,730 17.8% 44.4% 25.2%

$300,000+ 1 $378,276 4.9% 5 $2,570,863 24.3% 400.0% 579.6%

HCC Subtotal 24 $2,775,634 35.7% 29 $5,266,786 49.7% 20.8% 89.8%

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Additional Details

Oct 2023 - Sep 2024 Oct 2024 - Sep 2025 Top 5 HCC Diagnostic Categories by Paid Claimants Paid Paid/Claimant Paid % Claimants Paid Paid/Claimant Paid % Neoplasms 6 $847,065 $141,177 30.5% 6 $1,856,837 $309,473 35.3%

Perinatal 0 $0 $0 0.0% 4 $1,068,788 $267,197 20.3%

Circulatory 8 $748,878 $93,610 27.0% 4 $949,737 $237,434 18.0%

Musculoskeletal 0 $0 $0 0.0% 3 $296,916 $98,972 5.6%

Infectious/Parasitic 2 $439,421 $219,711 15.8% 1 $247,419 $247,419 4.7%

All others 8 $740,270 $92,534 26.7% 11 $847,090 $77,008 16.1%

Summary 24 $2,775,634 $115,651 100.0% 29 $5,266,786 $181,613 100.0%

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Diagnostic Categories

Rank Relationship Age/Gender

Band Leading Diagnostic Category Leading Diagnosis Inpatient Paid Outpatient

Paid Professional

Paid Pharmacy Paid Total Paid Prior HCC Prior Period

Paid

1 Subscriber Male 40-49 Neoplasms Non-Hodgkin lymphoma $618,604 $229,454 $62,709 $21,446 $932,213 NO $17,473

2 Subscriber Female 50-59 Circulatory Gangrene $312,798 $39,519 $90,983 $4,401 $447,701 YES $57,670

3 Spouse Male 40-49 Neoplasms Bone cancer $81,341 $314,182 $15,079 $1,490 $412,092 NO $18,569

4 Dependent Male <1-19 Perinatal Short gestation; low birth weight; and fetal growth retardation $385,108 $1,960 $5,160 $25 $392,253 NO $549

5 Dependent Female <1-19 Perinatal Respiratory distress syndrome $381,532 $0 $5,061 $12 $386,605 NO $1,662

6 Subscriber Female 50-59 Infectious/Parasitic Septicemia $95,100 $15,148 $7,578 $129,592 $247,418 YES $229,863

7 Subscriber Male 60-64 Circulatory Coronary atherosclerosis and other heart disease $189,351 $0 $13,609 $7,989 $210,949 NO $12,787

8 Spouse Female 50-59 Neoplasms Breast cancer - all other types $0 $14,278 $62,104 $96,952 $173,334 NO NA

9 Subscriber Male 40-49 Circulatory Cerebral infarction $150,999 $0 $10,542 $0 $161,541 NO NA

10 Dependent Male <1-19 Perinatal Short gestation; low birth weight; and fetal growth retardation $149,393 $0 $1,991 $0 $151,384 NO NA

11 Dependent Female <1-19 Perinatal Respiratory distress syndrome $136,143 $0 $2,403 $0 $138,546 NO NA

12 Subscriber Male 50-59 Circulatory Nonrheumatic and unspecified valve disorders $81,354 $36,458 $11,541 $193 $129,546 NO $10,901

13 Subscriber Female 30-39 Neoplasms Urinary system cancers - kidney $0 $2,306 $2,118 $113,464 $117,888 NO $19,241

14 Subscriber Female 60-64 Musculoskeletal Spondylopathies/spondyloarthropathy (including infective) $72,567 $15,160 $18,817 $10,593 $117,137 YES $61,146

15 Subscriber Male 60-64 Neoplasms Gastrointestinal cancers - colorectal $0 $15,438 $94,542 $6,829 $116,809 NO $6,931

16 Dependent Female <1-19 Injury/Poisoning Fracture of the upper limb, initial encounter $94,826 $6,777 $7,374 $12 $108,989 NO NA

17 Subscriber Female 50-59 Musculoskeletal Spondylopathies/spondyloarthropathy (including infective) $0 $0 $2,272 $104,415 $106,687 YES $221,332

18 Subscriber Male 40-49 Neoplasms Gastrointestinal cancers - colorectal $22,710 $48,750 $14,207 $18,834 $104,501 YES $208,919

19 Subscriber Male 50-59 Genitourinary Calculus of urinary tract $27,583 $37,073 $19,371 $15,126 $99,153 NO $17,954

20 Subscriber Female 50-59 Eye Cataract and other lens disorders $0 $1,662 $2,146 $90,789 $94,597 NO $17,010

* NA : member was not enrolled in prior period

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Listing

Variance

Medical Pharmacy Paid

PMPM $28.64 $51.13 78.5% $58.47 -12.5%

Non High Cost $10.12 $8.84 -12.7% $14.89 -40.6%

High Cost $18.51 $42.29 >100% $43.58 -3.0%

Paid/Claimant $778 $1,373 76.5% $1,545 -11.1%

Claimants/1,000 442.0 447.0 1.1% 429.1 4.2%

Special Medical Pharmacy Paid PMPM $14.95 $25.66 71.6% $33.76 -24.0%

Gene and Cell Therapy Paid

PMPM 0.0% $1.97 -100.0%

Med Rx as % of Total Paid 10.9% 13.1% 13.6%

• Total paid PMPM for Medical Pharmacy increased by 78.5% in the current reporting period and was 12.5%below the benchmark.

• Neoplasms was the most costly diagnostic category for Medical Pharmacy and paid PMPM increased by 122.9% between reporting periods.

• J9271 - KEYTRUDA was the most costly drug for Medical Pharmacy and paid PMPM increased by 0.0% between reporting periods.

Medical Pharmacy Paid PMPM by Top-3 Diagnostic Categories

Medical Pharmacy Paid — PMPM Top-5 Drugs*

Neoplasms accounted for 60.3% of the total Medical Pharmacy Paid PMPM in the current period.

*Leading diagnostic category for each drug is listed under drug name.

Pa id

P M

PM

$0.00 J9271 - KEYTRUDA

Neoplasms

J2350 - OCREVUS

Nervous

J9358 - ENHERTU

Neoplasms

J9263 - ELOXITAN

Neoplasms

Q5101 - ZARXIO

Neoplasms

Prior $0.00 $1.81 $0.00 $0.06 $0.00

Current $12.93 $3.99 $1.63 $1.59 $1.46

Benchmark $3.45 $1.54 $0.37 $0.21 $0.04

Pa id

P M

PM

$0.00 Neoplasms Nervous Health Status

Prior $13.83 $2.85 $2.69

Current $30.83 $4.44 $3.43

Benchmark $20.01 $6.36 $5.53

Report Description: Medical Pharmacy applies only to drugs paid under the Medical Plan.

CITY OF EDINBURG 000243483: ALL.

Medical Pharmacy

• Inpatient paid PMPM increased by _>100%_between the two reporting periods and was 47.1%_higher than_the benchmark.

• High Cost Claimants accounted for 87.8%_of total inpatient spend compared to 58.0%_from the previous reporting period.

• Admissions/1,000 increased by _11.3%_between reporting periods and was 10.5%_higher than_the benchmark.

• Perinatal_was the most costly diagnostic category for inpatient services in the current reporting period. It increased_>100%_and was >100%_higher than_ the benchmark.

Reporting Period Oct 2023 - Sep 2024

Oct 2024 - Sep 2025 % Change Benchmark

Benchmark Variance

Allowed $1,983,877 $3,522,474 77.6% Allowed PMPM $94.77 $171.73 81.2% $120.73 42.2% Paid $1,397,826 $3,206,249 >100% Paid PEPM $105.98 $243.14 >100% $201.73 20.5% Paid PMPM $66.78 $156.31 >100% $106.27 47.1% Non-High Cost $28.04 $19.12 -31.8% $23.87 -19.9% High Cost $38.73 $137.19 >100% $82.40 66.5%

Admissions 77 84 9.1% Admissions/1,000 44.1 49.1 11.3% 44.5 10.5% Days/1,000 206.9 273.8 32.3% 238.5 14.8% Average Length of Stay 4.7 5.6 18.8% 5.4 3.9% Paid/Admission $18,154 $38,170 >100% $28,677 33.1% In-Network Paid % 100.0% 100.0% 99.3% In-Network Admissions % 100.0% 100.0% 98.8%

CITY OF EDINBURG 000243483: ALL

Inpatient Facility Overview

Inpatient Paid PMPM by Service Type Inpatient Admissions/1,000 by Service Type

Inpatient Paid/Admission by Service Type Inpatient Average Length of Stay (ALOS) by Service Type2023

Ad m iss io ns /1

,0

0 Medical Surgical Maternity Complex Newborns

Post-Acute Care

Prior 16.1 13.8 8.0 1.1 0.6

Current 21.6 9.4 8.8 6.4 1.8

Benchmark 15.6 9.0 9.7 3.9 1.3

Pa id

P M

PM

$0 Complex Newborns

Surgical Medical Post-Acute Care Maternity

Prior $0.86 $38.92 $19.00 $0.70 $5.67

Current $51.11 $45.49 $40.96 $11.55 $6.89

Benchmark $8.68 $49.20 $31.03 $4.30 $8.46

AL

O

S

0 Post-Acute Care Complex Newborns

Surgical Mental Health Medical

Prior 60.0 5.0 5.2 4.4 3.6

Current 25.0 8.5 7.9 4.0 3.6

Benchmark 18.1 5.9 5.3 11.0 4.1

Pa id

/ A dm iss io n

$0 Complex Newborns

Post-Acute Care Surgical Medical Maternity

Prior $9,008 $14,631 $33,949 $14,204 $8,475

Current $95,311 $78,955 $58,320 $22,708 $9,416

Benchmark $26,896 $38,924 $65,840 $23,933 $10,478

CITY OF EDINBURG 000243483: ALL

Inpatient Facility - Details by Top 5 Service Types

Normal Delivery and C-Section Overview:

Paid PMPM Admissions/1,000 Paid/Admission

Reporting Period Oct 2023 - Sep 2024

Oct 2024 - Sep 2025 % Change Benchmark

Benchmark Variance

Paid $87,821 $125,791 43.2%

Paid PMPM $4.20 $6.13 46.2% $7.26 -15.6%

Admissions 13 15 15.4%

C-Section Delivery 5 7 40.0%

Normal Delivery 8 8 0.0%

Admissions/1,000 7.5 8.8 17.8% 9.0 -2.3%

Days/1,000 14.3 18.7 30.6% 23.2 -19.4%

Average Length of Stay 1.9 2.1 10.9% 2.6 -17.5%

C-Section Delivery 2.2 2.9 29.9% 3.3 -12.6%

Normal Delivery 1.8 1.5 -14.3% 2.2 -32.7%

Paid/Admission $6,755 $8,386 24.1% $9,704 -13.6%

Average Mother Age 28.9 33.0 14.4% 30.6 7.9%

The C-Section rate was 47%_which is above_the benchmark (36%) .

$0 Normal Delivery C-Section Delivery

Prior $5,570 $8,652

Current $7,128 $9,824

Benchmark $8,023 $12,916

0 Normal Delivery C-Section Delivery

Prior 4.6 2.9

Current 4.7 4.1

Benchmark 5.9 3.1

$0.00 Normal Delivery C-Section Delivery

Prior $2.13 $2.07

Current $2.78 $3.35

Benchmark $3.94 $3.32

CITY OF EDINBURG 000243483: ALL

Inpatient Deliveries

Oct 2024 - Sep 2025

Top Inpatient Providers by Admissions

Provider State

Admissions Paid % of Total Paid

Paid/ Admission

DOCTORS HOSPITAL AT RENAISSANCE, LTD TX 25 $594,646 18.6% $23,785.83

MCALLEN HOSPITALS L P TX 21 $341,802 10.7% $16,276.26

UNIVERSITY OF TEXAS M. D. ANDERSON CANCER CENTER TX 13 $700,253 21.8% $53,865.61

COLUMBIA RIO GRANDE HEALTHCARE, L.P. TX 10 $256,680 8.0% $25,667.99

DRISCOLL CHILDRENS HOSPITAL TX 7 $1,113,900 34.7% $159,128.52

MISSION HOSPITAL, INC. TX 3 $22,894 0.7% $7,631.45

CHG HOSPITAL MCALLEN, LLC TX 2 $54,387 1.7% $27,193.50

VHS HARLINGEN HOSPITAL COMPANY LLC TX 1 $95,100 3.0% $95,100.45

FANNIN COUNTY HOSPITAL AUTHORITY TX 1 $13,300 0.4% $13,300.00

OHIOHEALTH CORPORATION OH 1 $13,287 0.4% $13,287.21

All Other 0.0% $0.00

Summary 84 $3,206,249 100.0% $38,169.63

• DOCTORS HOSPITAL AT RENAISSANCE, LTD_was the most frequently utilized inpatient facility.

• The top inpatient facility by paid amount was_DRISCOLL CHILDRENS HOSPITAL, which accounted for 34.7% of the total inpatient paid amount in the current reporting period.

• The top 10 inpatient providers accounted for 100.0%_of the total inpatient spend in the current reporting period._

CITY OF EDINBURG 000243483: ALL

Inpatient Provider Summary

Sep 2024

Oct 2024 - Sep 2025 % Change Benchmark

Benchmark Variance

Allowed $3,015,196 $3,397,474 12.7% Allowed PMPM $144.04 $165.63 15.0% $201.41 -17.8% Paid $2,386,977 $2,636,289 10.4% Paid PEPM $180.98 $199.92 10.5% $297.63 -32.8% Paid PMPM $114.03 $128.52 12.7% $153.83 -16.4% Non-High Cost $66.22 $81.95 23.7% $84.89 -3.5% High Cost $47.81 $46.58 -2.6% $68.93 -32.4%

Visits 2,133 2,201 3.2% Visits/1,000 1,222.8 1,287.6 5.3% 1,266.7 1.7% Paid/Visit $1,119 $1,198 7.0% $1,457 -17.8% In-Network Paid % 100.0% 100.0% 99.2% In-Network Visits % 100.0% 98.3% 98.2%

• Outpatient paid PMPM increased by _12.7%_between the two reporting periods and was 16.4%_ lower than_the benchmark.

• High Cost Claimants accounted for 36.2%_of total outpatient spendcompared to 41.9%_from the previous reporting period.

• Neoplasms_was the most costly diagnostic category for outpatient services in the current reporting period. It increased_1.8%_and was 13.3%_ higher than_the benchmark.

CITY OF EDINBURG 000243483: ALL

Outpatient Facility Overview

Outpatient Paid PMPM by Service Type

Outpatient Visits/1,000 by Service Type Outpatient Paid/Visit by Service Type

• Surgical_was the service type with the highest paid PMPM for outpatient services in the current reporting period. Paid PMPM increased_18.6%_and was 30.3%_lower than_the benchmark.

• Pathology & Laboratory_had the highest rate of visits/1,000 in the current reporting period.

• Surgical_had the highest amount paid per visitin the current reporting period.Pa id

P M

PM

$0 Surgical ER Pharmacy & IV Therapy

Pathology & Laboratory

Radiology

Prior $35.07 $25.57 $14.46 $14.52 $17.15

Current $41.60 $30.28 $16.90 $15.82 $13.10

Benchmark $59.64 $37.45 $15.83 $5.11 $17.08

Vi sit s/ 1, 0 Pathology & Laboratory

ER Radiology Other Outpatient

Services

PT/OT/ST

Prior 456.9 189.7 218.4 78.0 70.5

Current 478.5 213.5 183.7 115.2 97.7

Benchmark 207.9 230.4 192.4 98.3 188.3

Pa id

/ V isi t

$0 Surgical Pharmacy & IV Therapy

Observation ER Radiology

Prior $5,520 $3,254 $1,739 $1,617 $942

Current $5,651 $4,030 $2,089 $1,702 $856

Benchmark $6,228 $4,211 $1,586 $1,951 $1,066

CITY OF EDINBURG 000243483: ALL

Outpatient Facility - Details by Top 5 Service Types

• ER paid PMPM_increased by _18.4%_between the two reporting periods and was 19.2%_ lower than_the benchmark.

• ER visits/1,000 increased _12.5%_between reporting periods and was 7.3%_ lower than_the benchmark.

• Spouses_had the highest ER visits/1,000 rate in the current period.

ER Visits/1,000 by Relationship

Oct 2023 - Sep 2024

Oct 2024 - Sep 2025 % Change Benchmark

Benchmark Variance

ER Allowed $882,600 $1,035,991 17.4% ER Paid $535,270 $621,121 16.0% ER Allowed PMPM $42.16 $50.51 19.8% $54.27 -6.9% ER Paid PMPM $25.57 $30.28 18.4% $37.47 -19.2% ER Visits 331 365 10.3% ER Visits/1,000 189.7 213.5 12.5% 230.4 -7.3% ER Allowed/Visit $2,666 $2,838 6.4% $2,826 0.4% ER Paid/Visit $1,617 $1,702 5.2% $1,951 -12.8% % of ER Claimants with 3+ Visits 6.0% 8.9% 9.9%

Total ER Allowed/Visit* $3,103 $3,357 8.2% $3,333 0.7% Total ER Paid/Visit* $1,768 $1,922 8.7% $2,320 -17.2%

*Includes physician charges

Oct 2023 - Sep 2024

Oct 2024 - Sep 2025 % Change Benchmark

Benchmark Variance

Employee 175.6 199.3 13.5% 243.0 -18.0%

Spouse 310.1 312.2 0.7% 261.6 19.3%

Dependent 192.7 223.3 15.9% 227.9 -2.0%

CITY OF EDINBURG 000243483: ALL

Emergency Room Overview

Top ER Diagnoses for Oct 2024 - Sep 2025

ER Diagnosis Paid Claimants Visits %Visits Potentially

Non-Emergent * Injury/Poisoning $83,751 59 65 1.5%

Genitourinary $71,343 32 37 45.9%

Respiratory $38,136 31 34 82.4%

Infectious/Parasitic $58,911 29 31 22.6%

Symptoms/Ill-Defined $46,463 24 26 57.7%

Digestive $46,816 22 23 39.1%

Musculoskeletal $46,102 23 23 47.8%

Circulatory $53,168 20 22 9.1%

Pregnancy $36,834 12 22 13.6%

Mental Health $22,238 10 12 0.0%

All Others $117,359 66 73 17.8%

Summary $621,121 270 365 28.8%

• 28.8%_of ER visits were potentially non-emergent in the current reporting period compared to 29.9%_in the prior reporting period and 29.3%_for the benchmark.

• The conditions with the highest volume of ER visits in the current reporting period were_Injury/Poisoning_, _Genitourinary_, and _Respiratory.

* Not reflective of benefit design

CITY OF EDINBURG 000243483: ALL

Emergency Room Leading Diagnoses

• 9%_of ER claimants visited the ER three or more times in the current reporting period compared to 6%_in the prior reporting period and 10%_for the benchmark.

• Claimants with 3 or more ER visits accounted for 22%_of the ER paid expenses in the current reporting period compared to_16%_in the prior reporting period and 31%_for the benchmark.

ER Visits Claimants Claimants % of Total ER Visits ER Paid 1 208 77.0% 208 $351,894

2 38 14.1% 76 $133,881

3 18 6.7% 54 $91,676

4 4 1.5% 16 $26,471

5 1 0.4% 5 $8,117

6 1 0.4% 6 $9,082

10+

Summary 270 100% 365 $621,121

ER Utilization and Costs by Number of Visits for Oct 2024 - Sep 2025

Diagnosis ER Paid ER Visits Claimants Genitourinary $29,400 12 8

Blood $15,373 3 1

Symptoms/Ill-Defined $13,526 7 5

Pregnancy $13,074 9 3

Respiratory $11,774 10 7

Top Diagnoses of Claimants with 3+ ER Visits for Oct 2024 - Sep 2025

CITY OF EDINBURG 000243483: ALL

Frequent Users Of The Emergency Room

Oct 2024 - Sep 2025

Top Outpatient Providers by Visits

Provider State

Visits Paid % of Total Paid

Paid/ Visit

DOCTORS HOSPITAL AT RENAISSANCE, LTD TX 1,202 $702,079 26.6% $584.09

MCALLEN HOSPITALS L P TX 335 $442,100 16.8% $1,319.70

COLUMBIA RIO GRANDE HEALTHCARE, L.P. TX 147 $270,092 10.3% $1,837.36

HARLINGEN VAMC TX 129 $50,117 1.9% $388.50

UNIVERSITY OF TEXAS M. D. ANDERSON CANCER CENTER TX 72 $631,282 24.0% $8,767.81

DRISCOLL CHILDRENS HOSPITAL TX 62 $308,363 11.7% $4,973.60

TEN LAC INC TX 52 $4,899 0.2% $94.21

MISSION HOSPITAL, INC. TX 37 $75,613 2.9% $2,043.59

THERAPY SQUAD, LLC TX 37 $456 0.0% $12.32

RENAISSANCE HOSPICE AND PALLIATIVE CARE, LLC TX 18 $3,564 0.1% $198.00

All Other 110 $147,724 5.6% $1,342.94

Summary 2,201 $2,636,289 100.0% $1,197.77

• DOCTORS HOSPITAL AT RENAISSANCE, LTD_was the most frequently utilized outpatient facility.

• The top outpatient facility by paid amount was DOCTORS HOSPITAL AT RENAISSANCE, LTD, which accounted for 26.6%_of the total outpatient paid amount in the current reporting period.

• The top 10 outpatient providers accounted for 94.4%_of the total outpatient spend in the current reporting period.

CITY OF EDINBURG 000243483: ALL

Outpatient Provider Summary

Sep 2024

Oct 2024 - Sep 2025 % Change Benchmark

Benchmark Variance

Allowed $2,332,113 $2,796,187 19.9%

Allowed PMPM $111.41 $136.32 22.4% $187.73 -27.4%

Paid $1,734,211 $2,160,611 24.6%

Paid PEPM $131.49 $163.84 24.6% $288.18 -43.1%

Paid PMPM $82.85 $105.33 27.1% $146.42 -28.1%

Non-High Cost $65.19 $74.03 13.6% $97.82 -24.3%

High Cost $17.65 $31.30 77.3% $48.60 -35.6%

Visits/1,000 8,160.9 9,009.9 10.4% 9,421.6 -4.4%

Services/1,000 20,526.1 21,940.1 6.9% 21,014.1 4.4%

Paid/Visit $122 $140 15.2% $186 -24.8%

Paid/Service $48 $58 19.0% $84 -31.1%

In-Network Paid % 99.8% 99.6% 99.0%

In-Network Visits % 98.6% 99.4% 98.3%

• Professional paid PMPM increased by_27.1%_between the two reporting periods and was 28.1%_ lower than_the benchmark.

• High Cost Claimants accounted for 29.7%_of total professional spend compared to 21.3%_from the previous reporting period.

• Health Status_was the most costly diagnostic category for professional services in the current reporting period.

It increased_6.5%_and was 14.0%_lower than_the benchmark.

• Primary Care Physicians accounted for_38.6%_of the total professional visitsin the current reporting period.

CITY OF EDINBURG 000243483: ALL

Professional Services Overview

Professional Paid PMPM by Service Type

Professional Services/1,000 by Service Type Professional Paid/Service by Service Type

• Evaluation & Management_was the service type with the highest paid PMPM for professional services in the current reporting period. Paid PMPM increased_21.5%_and was 13.1%_lower than_the benchmark.

• Evaluation & Management_had the highest rate of services/1,000 in the current reporting period.

• Anesthesia_had the highest amount paid per service in the current reporting period.

Pa id

P M

PM

$0 Evaluation & Management

Pathology & Laboratory

Medical Medical Services & Supplies

(HCPCS II)

Surgical

Prior $42.55 $12.41 $8.58 $5.61 $5.20

Current $51.70 $13.93 $13.73 $11.48 $6.19

Benchmark $59.51 $7.77 $18.62 $28.59 $16.13

Se rv ic e/

1, 0 Evaluation & Management

Pathology & Laboratory

Medical PT/OT/ST Radiology

Prior 11,450.8 5,467.2 1,400.5 679.9 662.7

Current 11,777.7 5,734.4 1,949.9 841.3 699.7

Benchmark 9,511.3 4,277.6 2,515.8 1,688.6 744.6

Pa id

/ S er vi ce

$0 Anesthesia Medical Services & Supplies

(HCPCS II)

Surgical Medical Radiology

Prior $360 $157 $177 $73 $64

Current $389 $289 $196 $85 $65

Benchmark $642 $292 $195 $89 $93

CITY OF EDINBURG 000243483: ALL

Professional - Details by Top 5 Service Types

Cancer Screenings:

Oct 2023 - Sep 2024 Oct 2024 - Sep 2025 Benchmark Cervical Cancer Screening 30.0% 30.2% 26.1%

Colorectal Cancer Screening 11.6% 11.4% 13.7%

Mammogram Screening 41.9% 37.3% 47.2%

PCP Care:

Oct 2023 - Sep 2024 Oct 2024 - Sep 2025 Benchmark Annual Physical 27.7% 26.7% 41.4%

Childhood Immunizations 57.8% 53.6% 65.7%

Well Infant Care 78.6% 63.2% 81.5%

Well Young Child Care 61.7% 69.7% 68.8%

Well School-Age Child Care 50.5% 48.2% 51.4%

Percentages represent utilization of preventive services by those members for which the service is deemed appropriate.

Compliance rates for well infant care, well young child care,well school-age child care, and childhood immunizations are based on utilization for claimants (not members) for whom the service is deemed appropriate, in order to account for newborn children who have little to no enrollment data.

CITY OF EDINBURG 000243483: ALL

Preventive Care

Metric Oct 2023 - Sep 2024 Oct 2024 - Sep 2025 % Change Benchmark

Variance

Paid $2,256,451 $2,594,802 15.0%

Paid PMPM $107.79 $126.50 17.4% $150.19 -15.8%

Member Cost Share % 6.9% 6.2% 9.2%

Paid/Claimant $1,628.03 $1,910.75 17.4% $1,940.47 -1.5%

Paid/Day $4.61 $5.31 15.3% $6.23 -14.7%

Prescriptions 19,898 19,423 -2.4%

Prescriptions/1000 11,406.7 11,362.9 -0.4% 12,856.8 -11.6%

Claimants 1,386 1,358 -2.0%

Claimants/1000 794.5 794.5 0.0% 852.4 -6.8%

Scripts/Claimant 14.4 14.3 -0.4% 13.5 5.8%

Generic Dispensing Rate 85.3% 84.8% 87.2%

Rx Retail as % of Prescriptions 99.8% 99.8% 97.5%

Rx Mail Order as % of Prescriptions 0.2% 0.2% 2.5%

Specialty % of Total Prescriptions 0.4% 0.6% 0.9%

Specialty % of Pharmacy Cost 25.5% 34.2% 48.2%

• Pharmacy Paid PMPM_increased _17.4%_and was 15.8%_ below_the benchmark in the current period.

• Prescriptions/1000 decreased _0.4%_and was 11.6%_ below_the benchmark.

• The Generic Dispensing Ratedecreased _0.5%_to 84.8%_and was 2.4%_ lower than_the benchmark.

• Specialty Drugs accounted for 34.2% of the pharmacy spend in the current period compared to 25.5%_in the prior period and 48.2%_in the benchmark.

Generic Dispensing Rate (GDR) vs. Benchmark

CITY OF EDINBURG 000243483: ALL

Pharmacy Overview

Top 10 Non-Specialty Drugs by Ingredient Cost: Current Period

Current/ Prior Rank Drug Product Name Plan Therapeutic Class Prescriptions

Utilizing Members Ingredient Cost

Avg. Ingredient Cost/

Prescription (Current)

Avg. Ingredient Cost/

Prescription (Prior)

Generic Indicator

Rank by Volume

1 2 MOUNJARO Incretin Mimetic Agents 461 55 $462,897 $1,004.11 $986.23 NO 7

2 1 OZEMPIC Incretin Mimetic Agents 440 68 $363,745 $826.69 $839.02 NO 8

3 4 JARDIANCE Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 197 33 $97,964 $497.28 $515.51 NO 20

4 5 FARXIGA Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 159 19 $84,280 $530.06 $519.53 NO 22

5 3 PAXLOVID Antiviral Combinations 59 62 $81,558 $1,382.34 $1,065.03 NO 75

6 7 RYBELSUS Incretin Mimetic Agents 85 10 $78,139 $919.29 $874.34 NO 49

7 6 SYNJARDY XR Antidiabetic Combinations 139 16 $60,452 $434.91 $418.06 NO 27

8 10 SYNJARDY Antidiabetic Combinations 84 10 $39,359 $468.56 $495.88 NO 50

9 11 TRESIBA FLEXTOUCH Insulin 126 20 $35,826 $284.33 $299.85 NO 33

10 9 XIGDUO XR Antidiabetic Combinations 67 11 $33,448 $499.22 $460.36 NO 69

All Other 17,484 1,350 $532,128 $30.44 $30.45

Summary 19,301 1,357 $1,869,796 $96.88 $92.82

Top 10 Non-Specialty Drug Classes by Ingredient Cost: Current Period

Current/ Prior Rank Plan Therapeutic Class Prescriptions Utilizing Members Ingredient Cost

Avg. Ingredient Cost/ Prescription

(Current)

Avg. Ingredient Cost/ Prescription

(Prior) % Generic Rank by Volume

1 1 Incretin Mimetic Agents 1,010 128 $926,408 $917.24 $890.10 2

2 2 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 356 52 $182,244 $511.92 $516.95 15

3 3 Antidiabetic Combinations 360 46 $162,456 $451.27 $429.43 7.2% 13

4 4 Antiviral Combinations 59 62 $81,558 $1,382.34 $1,065.03 63

5 5 Insulin 177 28 $51,389 $290.33 $300.52 29

6 14 Calcitonin Gene-Related Peptide (CGRP) Receptor Antag 33 6 $45,008 $1,363.87 $1,551.67 94

7 6 Sympathomimetics 271 144 $32,415 $119.61 $115.72 64.9% 22

8 11 Cardiovascular Agents Misc. - Combinations 41 4 $22,031 $537.35 $608.36 4.9% 83

9 10 Direct Factor Xa Inhibitors 37 7 $19,704 $532.55 $510.69 92

10 7 Viral Vaccines 180 127 $15,973 $88.74 $92.71 28

All Other 16,777 1,325 $330,611 $19.71 $19.26 96.6%

Summary 19,301 1,357 $1,869,796 $96.88 $92.82 85.0%

CITY OF EDINBURG 000243483: ALL

Pharmacy: Top Non-Specialty Therapeutic Drug Classes

Report Description: Specialty drugs generally have unique uses, require special dosing or administration, are typically prescribed by a specialist provider and are significantly more expensive than alternative drugs or therapies. This report provides a specialty drug analysis overview.

Top 10 Specialty Drugs by Ingredient Cost for the Year to Date

Brand Name Specialty Class Ingredient

Cost Prescriptions

Avg. Ingredient Cost/

Prescription Specialty Claimants

ENBREL SRCLK INJ 50MG/ML AUTOIMMUNE $176,381 23 $7,668.75 2

REVLIMID CAP 10MG CANCER $127,577 7 $18,225.28 1

SKYRIZI PEN INJ 150MG/ML AUTOIMMUNE $106,424 11 $9,674.87 2

PIQRAY 200MG TAB DOSE CANCER $96,886 4 $24,221.62 1

HUMIRA PEN INJ 40/0.4ML AUTOIMMUNE $59,181 9 $6,575.65 1

STELARA INJ 45/0.5ML AUTOIMMUNE $53,848 10 $5,384.81 1

COSENTYX UNO INJ 300/2ML AUTOIMMUNE $50,987 7 $7,283.86 1

DUPIXENT INJ 300/2ML AUTOIMMUNE $49,668 13 $3,820.63 1

GENOTROPIN INJ 12MG GROWTH HORMONES $46,828 5 $9,365.67 1

ACTEMRA INJ ACTPEN AUTOIMMUNE $28,252 12 $2,354.32 1

All Other $95,840 21 $4,563.79 9 Summary $891,872 122 $7,310.43 18

Oct 2023 - Sep 2024 Oct 2024 - Sep 2025 % Change Benchmark Benchmark

Variance

Unique Pharmacy Members 2,023 1,994 -1.4%

Claimants 11 18 63.6%

Percent of Utilizing Members 0.5% 0.9% 1.4%

Prescriptions 84 122 45.2%

Specialty Percent of Total Paid 25.5% 34.2% 48.2%

Percent of Total Prescriptions Paid 0.4% 0.6% 0.9%

Paid $574,273 $887,777 54.6%

Paid PMPM $27.43 $43.28 57.8% $71.70 -39.6%

Average Ingredient Cost/Prescription $6,858 $7,310 6.6% $9,515 -23.2%

Prior period is reflected only as it pertains to the Top 5 Specialty Classes of current period.

CITY OF EDINBURG 000243483: ALL

Pharmacy: Specialty Drug Analysis

Demographics

Members Current Period

Prior Period

Number of

Procedur es/1000

Prior Year Number of Procedure s/1000

% change Benchmar k Variance

Employee 1,073 1,072 2,301 2,227 3.3% 2,912 -21.0%

Spouse 199 189 2,810 3,059 -8.2% 3,280 -14.3%

Dependent 518 538 3,964 3,368 17.7% 4,328 -8.4%

Totals 1,790 1,799 2,839 2,656

• Membership decreased by_0.5%_from the previous reporting period, while the number of procedures increased by_6.9%_ for the same time period._

• 36% of Total Members utilized their benefit during the current reporting period.

• DIAGNOSTICprocedures accounted for 63% of the total procedures for the account. Compared to 62%from the previous reporting period.

CITY OF EDINBURG 000243483: ALL

Dental Utilization Overview

• The_total paid amount increased by_22.5%_between reporting periods.

• Total in-network discounts(excluding Medicare) were $23,471,207_(73.4%)_for the current reporting period.

• The in-network paid percentage (excluding Medicare) was 99.9%_for the current reporting period.

Network Overview Oct 2024 - Sep 2025

Financial Order of Reduction (including Pharmacy)

Oct 2023 - Sep 2024 Oct 2024 - Sep 2025 % Change Billed $40,488,149 $41,279,884 2.0%

Not Covered $5,787,788 $3,991,811 -31.0%

Covered $34,700,361 $37,288,074 7.5%

Discount $24,871,865 $25,818,936 3.8%

Allowed $9,828,495 $11,469,138 16.7%

Out of Pocket $1,591,632 $1,677,528 5.4%

COB $11,817 $46,124 >100%

COB Medicare $417,973 $160,738 -61.5%

Other Reductions $2,370 $19,970 >100%

Other Adjustments ($481) ($7,500) <-100%

Paid - Provider $7,805,186 $9,572,278 22.6%

Other Payments $7,196 $498 -93.1%

Total Paid $7,812,382 $9,572,777 22.5%

Allowed PMPM $469.52 $559.14 19.1%

Paid PMPM $373.21 $466.69 25.0%

Plan Share 83.1% 85.1% 2.4%

Medicare Primary Indicator Network Indicator Covered Discount Discount % Paid % of Paid

No In-Network $31,984,874 $23,471,207 73.4% $6,974,940 99.9%

Out of Network $64,838 $34,254 52.8% $9,442 0.1%

Yes In-Network $170,052 $1,641 $1,173 0.0%

Out of Network $0 $0 $0 0.0%

Summary $32,219,763 $23,507,102 73.3%* $6,985,554 100.0%

Claims on paid basis

*Calculated discount percent excludes Medicare Primary.

CITY OF EDINBURG 000243483: ALL

Appendix: Financial Summary

Admin Fees: The charge to an account for HCSC's operational cost of doing business.

Administrative Services Only (ASO): A contract between HCSC and a self-funded plan where HCSC performs administrative services only and does not assume any financial risk.

Services usually include claims processing but may include other services such as actuarial analysis and utilization review.

Aggregate: Constituting or amounting to a whole. For example, an aggregate account report includes data for the entire account.

Aggregate Stop Loss: A form of reinsurance that provides protection for medical expenses above a certain limit, generally on a year-by-year basis. Aggregate stop loss provides protection against the accumulation of total claims for a group as a whole exceeding a stated level.

Allowed: Amount considered eligible for payment by the plan ASO Adjustments: An amount added or deducted from ASO (Administrative Services Only) fees. This includes Stop Loss Reimbursements.

Average Age: The difference between the claimant's year of enrollment and year of birth. Calculated using the measure Average Age divided by the members represented in the report.

Average Contract Size: The average number of members per subscriber. It is calculated as: Medical Members / Medical Subscribers Average Dependents: Calculated using the measure Member Months (filtered on the Relationship = Dependents) divided by the number of months in the report.

Average Ingredient Cost: Represents the cost of the medication and is determined from the lowest submission of the pharmacy network rate, Usual & Customary amount, or Maximum Allowable Cost (MAC) Average Members: Calculated using the measure Member Months divided by the number of months included in the report.

Average Subscribers: Calculated using the measure Subscriber Months divided by the number of months included in the report.

Billed: Amount submitted for payment by the provider Billing and Accounts Receivable System (BARS): An HCSC financial system where all Administrative Services Only (ASO) customer bills are generated.

Blue Card Access Fee: Interplan Teleprocessing Services fee charged on out-of-state claims for accessing the local plan's provider network Brand Formulary: Brand name medications that are listed on the formulary Brand Non-Formulary: Brand name medications that are not listed on the formulary Claimants: Number of individual members submitting a claim Claim Lag: The amount of time between the date a claim is incurred and the date the claim payment is made.

CITY OF EDINBURG 000243483: ALL

Appendix: Glossary

COB: Portion of amount considered eligible for payment that has been paid by another insurance company (Coordination of Benefits)

COB Medicare: Portion of amount considered eligible for payment that has been paid by Medicare COBRA Members: Consolidated Omnibus Budget Reconciliation Act - A federal law which requires most employers sponsoring group health plans to offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) when coverage under the plan would otherwise end.

Coinsurance: Portion of covered amount member is responsible to pay for the claim Co-payment: Flat rate that the member is responsible to pay for the claim Coverage Tier: Eligibility tiers which stratify enrollment data based on the employee and others enrolled under the employee's coverage. Varying benefits can be assigned to tiers.

Covered Amount: Amount eligible for payment based on the terms of the medical/dental benefits agreement.

DAW/1: Indicates that the physician has specified 'do not substitute' on the prescription.

DAW2:Indicates that the Physician has allowed a substitution, but the patient requested brand to be dispensed Deductible: Portion of annual deductible amount member is responsible to pay applied to the claim.

Dental Loss Ratio: Calculated as the Dental Paid Claims Amount divided by the Billed Dental Premium Amount Dental Paid Claims: An amount paid to cover the Health Plan's liability for dental services provided to members for claims that have been processed and approved for payment Discount: Amount of reduction from billed amount that has been negotiated with the provider Discount %: For medical claims, the discount percent is calculated as Discount / Covered Dispensing Rate: The proportion of total drugs claims a certain drug or drug type is being dispensed Drug Type: An indicator on each…